Vulnerable older adults and their families face multiple challenges in medical decision making, health communication, and the emotional distress involved in facing serious illness and death. Dr. Alexia Torke's research has focused on the communication, ethical, religious and spiritual aspects of decision making for those patients who are incapacitated and require a family surrogate to make decisions for them. This K24 award will provide support for Dr. Torke's program of research and will allow her additional protected time to pursue her passion for mentoring others. The specific aims of this K24 award are to: train future aging researchers to conduct high quality research focused on decision making and outcomes for vulnerable older adults and their family members; to study the experience of family surrogate decision makers, including the impact of communication quality on decision quality and family outcomes such as anxiety, depression, and posttraumatic stress; and to measure surrogates' religious and spiritual experiences to determine whether these factors are associated with medical decision making and the medical care that patients receive at the end of life. Dr. Torke' research topic is important because nearly half of hospitalized older adults are unable to make their own medical decisions and require a family member or other surrogate to make decisions for them. Her prior research has shown that many surrogates make decisions about life and death issues under conditions of high stress and often with poor support from clinicians. Surrogates rely on various sources of emotional support and sources of value to make medical decisions, including personal, religious and spiritual beliefs. However, both surrogates and clinicians report high levels of distress due to the emotional and communication challenges of making decisions for others. Although there is evidence from patient studies that religion is associated with preferences for more aggressive care at the end of life, this has not been studied for surrogates making decisions for others. As the population ages and a greater number of older adults are at risk for cognitive impairment, the importance of surrogate decision making will only increase. Understanding the mechanisms underlying high quality decision making will allow us to best support family members and to provide the best possible care to older adults. The projects proposed in this award will leverage a database of 359 older hospitalized adults and their surrogate decision makers that Dr. Torke has developed through funding from an R01 grant from the National Institute on Aging. Additional funding from the Indiana University Health Values Grant and the Greenwall Foundation allowed Dr. Torke to also collect data on the goals of care endorsed by the surrogate, care received at the end of life, and the religious and spiritual experiences of the surrogates. Project 1 will explore the impact of communication quality on decision making quality and surrogate well-being, such as posttraumatic stress. Project 2 will examine the religious and spiritual dimensions of the surrogates and will study whether these impact medical decision making as well as the actual care received by the 40% of our enrolled patients who died within the 6-month study observation period. The findings from these projects will inform the development of interventions to improve both the quality of medical care for incapacitated patients and the well-being of their family members. Dr. Torke is a tenured Associate Professor at Indiana University. Her clinical practice has involved palliative care and primary care for older, frail adults. She has mentored over 16 fellows, residents, graduate students and junior faculty in research related to medical decision making, communication and health outcomes for older adults. Her leadership roles at Indiana University, including her appointment as Associate Director of the IU Center for Aging Research (IUCAR), put her in a position to mentor early career investigators focused on patient oriented research. This award will provide her with protected time to further develop her own research program and expand the scope of her mentoring activities. Indiana University provides an ideal location for this work. Dr. Torke's primary appointment is in IUCAR, where there are 10 investigators conducting aging research. The institute has provided infrastructure, intramural funding and space for Dr. Torke's research. She is taking on increasing responsibilities in the mentorship of research fellows and junior faculty. Through leadership roles at IU Health, Dr. Torke mentors a chaplain researcher and has mentored numerous ethics fellows, including physicians and PhD-prepared scientists who are embarking on research careers. Additional resources such as the Indiana Clinical and Translational Sciences Institute (CTSI) enrich opportunities for mentees to obtain research training through the Clinical Investigation and Translational Education (CITE) program and funding support through the KL2 career development awards.